The National Clinical Care Commission Report: Improving Federal Programs That Impact Diabetes Prevention and Care

In 2017, Congress passed the National Clinical Care Commission Act (Public Law 115-80). It directed the Secretary of the U.S. Department of Health and Human Services (HHS) to convene a committee to evaluate and make recommendations to Congress and the HHS Secretary regarding federal programs that impact diabetes and its complications. The National Clinical Care Commission (NCCC) was charged with evaluating and making recommendations regarding federal programs that prevent and reduce diabetes and its complications, support clinicians, provide education and awareness for health care professionals and the public, and identify opportunities to consolidate overlapping or duplicative programs related to diabetes. The NCCC included 23 members with expertise in diabetes epidemiology, public health, clinical care, patient advocacy, health policy, and regulatory matters.

The NCCC’s final report was submitted to Congress on 5 January 2022. Herein we provide a synopsis of its recommendations (1). Several recommendations directly address administrative barriers that clinicians regularly face on behalf of their patients, such as improving access to lifestyle change and education programs, diabetes devices, and insurance coverage for evidence-based prevention and treatment strategies. We believe the NCCC recommendations can serve as the basis for a national strategy to reduce the incidence of diabetes and improve care for people at risk for and with diabetes.

NCCC Approach to Its Charge

The burden of diabetes has reached epidemic proportions. This is of great importance to specialists in internal medicine. More than 34 million people in the United States, 13% of adults, have diabetes (2). About 90% to 95% have type 2 diabetes and 5% to 10% have type 1 diabetes (3). More than 20% of adults with diabetes remain undiagnosed (2). In addition, approximately 88 million U.S. adults have prediabetes, which carries risk for incident type 2 diabetes, and about 85% are unaware of their condition (2, 4). In 2017, direct medical costs from diabetes were $237 billion and two thirds of these costs were paid by Medicare and Medicaid (5). Diabetes contributes to heath inequities in the United States, and social and environmental factors are strong determinants of type 2 diabetes incidence, progression, and complications (6, 7). There have been major advances in diabetes prevention and treatment, but translation into practice has been slow and benefits have been experienced unequally. In addition, the national response to diabetes has focused on clinical aspects. It is critical that the epidemic be addressed via multisector societal, environmental, and public health approaches. Accordingly, the NCCC applied the broad perspectives provided by the socioecologic (8) and chronic care (9) models. Details about the NCCC’s process for gathering information and drafting recommendations are contained in the full report (1).

Commission Recommendations

Some of the issues identified by the NCCC were relevant to all types of diabetes, and some were specific to type 1 or type 2 diabetes. The general term “diabetes” was used in recommendations relevant to all types of diabetes; those specific to type 1 or type 2 diabetes used those terms.

The NCCC identified several opportunities to improve diabetes prevention and care through greater coordination of health-related and non-health-related federal agencies. The NCCC made 39 recommendations that require administrative action by federal agencies or departments, or legislative action by Congress. These are summarized in the Table and grouped by their impact on federal policies and programs, population-level interventions, type 2 diabetes prevention, insurance coverage, care delivery, and research. Each recommendation contains more specific and detailed content provided in the full report (1).

Table.

Summary of the National Clinical Care Commission Recommendations^*

Recommendations, by Topic Area
Federal programs and policies
Create an Office of National Diabetes Policy to develop and implement a national diabetes strategy that works across federal agencies and departments. (Recommendation 3.1)
Ensure that all people at risk for and with diabetes have access to comprehensive, high-quality, and affordable health care. (Recommendation 3.2)
Health equity should be a component of all federal policies and programs that affect people at risk for and with diabetes. (Recommendation 3.3)
Population-level programs to prevent diabetes, facilitate treatments, and promote health equity
USDA Supplemental Nutrition Assistance Program should be enhanced to reduce food insecurity and improve nutrition sufficiency. (Recommendation 4.1)
Other USDA programs should be enhanced to prevent type 2 diabetes in women, children, and adolescents. (Recommendation 4.2)
USDA should be resourced to create an environmentally friendly and sustainable food system promoting the production, supply, and accessibility of foods that will attenuate the risk for diabetes and its complications. (Recommendation 4.3)
Federal agencies should promote the consumption of water and reduce the consumption of sugar-sweetened beverages. (Recommendation 4.4)
FDA should improve food and beverage labeling regulations that influence both food and beverage industry practices and consumer behavior to better prevent and control diabetes. (Recommendation 4.5)
FTC should be provided authority to create and enforce guidelines regarding marketing of calorie-dense and nutrient-poor foods and beverages to children younger than 13 years old. (Recommendation 4.6)
Federal agencies regulating the ambient and built environments should modify their policies, practices, regulations, and funding decisions to promote environmental changes to prevent and control diabetes. (Recommendation 4.8)
HUD should increase housing opportunities for low-income individuals and families so that such individuals and families are housed in health-promoting environments. (Recommendation 4.9)
Type 2 diabetes prevention
Promote and support breastfeeding to increase rates, enhance intensity and duration, and reduce disparities among mothers who breastfeed. (Recommendation 4.7)
Increase support for the CDC campaign to raise awareness of prediabetes and promote enrollment in the National DPP lifestyle change program. (Recommendation 5.1)
Implement the American Medical Association-proposed prediabetes quality measures on screening for abnormal blood glucose levels, interventions for prediabetes, and retesting abnormal blood glucose levels in patients with prediabetes. (Recommendation 5.3)
Approve the Medicare DPP as a permanent covered benefit, remove the once-in-a-lifetime limits, and expand coverage to include virtual delivery. (Recommendation 5.7)
Streamline the CDC recognition process for the National DPP and CMS payment process for the Medicare DPP while maintaining quality and reducing or eliminating differences in program eligibility and duration. (Recommendation 5.8)
Support the testing of new payment models that allow for greater upfront payments, equitable risk sharing between CMS and Medicare DPP delivery organizations, and increase payment levels to allow such programs to be financially sustainable. (Recommendation 5.9)
Provide financial incentives to state Medicaid programs to cover the National DPP and other evidence-based interventions that meet or exceed those of the National DPP quality standards, including in-person, online, distance learning, or telehealth interventions. (Recommendation 5.10)
Fund the Special Diabetes Program for Indians in 5-year increments with annual increases addressing inflation costs and increase funding to HRSA Delta States Network Grant Program to include diabetes prevention as a focus. (Recommendation 5.11)
Insurance coverage
Require insurers to cover hemoglobin A1c testing when used to screen for prediabetes. (Recommendation 5.2)
Require insurers to cover participation in and completion of a CDC-recognized diabetes prevention program. (Recommendation 5.5)
Require insurers to cover all proven-effective modes of delivery of evidence-based diabetes prevention interventions that produce successful participant outcomes and meet or exceed those of the National DPP quality standards. (Recommendation 5.6)
Remove cost barriers to ensure that insulin is affordable. (Recommendation 6.9)
Require insurers to cover (pre-deductible) high-value diabetes services and treatments that prevent or delay progression of diabetes complications. (Recommendation 6.10)
Diabetes care delivery
Update the 2000 Medicare Quality Standards that govern diabetes self-management training and establish a process for ongoing review and updating to ensure eligibility, documentation, and reimbursement requirements are clearly defined and consistently applied. (Recommendation 6.1)
Develop reimbursement mechanisms for community-based diabetes education programs when evidence shows that these programs improve diabetes outcomes. (Recommendation 6.2)
Update the eligibility requirements for diabetes devices and establish a process for ongoing review and updating to ensure eligibility, documentation, and reimbursement requirements are clearly defined and consistently applied. The review process should consider both glycemic benefits and nonglycemic benefits, such as quality of life and diabetes distress. (Recommendation 6.3)
Ensure an adequate clinical workforce that can enhance and sustain team-based care for people with diabetes. (Recommendation 6.4)
Enhance implementation and sustainability of community health workers as critical members of diabetes care teams. (Recommendation 6.5)
Support use of virtual care modalities and increase access to telehealth services. (Recommendation 6.6)
Implement a quality measure to assess potential overtreatment, inappropriate treatment, or risk for harm from severe hypoglycemia among Medicare beneficiaries with diabetes and life-limiting conditions. (Recommendation 6.8)
CMMI should fund a demonstration project with HRSA and the IHS that uses a technology-enabled collaborative learning and capacity-building model to support uptake and implementation of diabetes care best practices among primary care providers and care teams. (Recommendation 6.7)
Diabetes research
Fund research at the population level with a focus on social and environmental conditions associated with diabetes and its complications. (Recommendation 4.10)
NIH should collect, analyze, and summarize data from the DPP study that describes effectiveness and safety of metformin for diabetes delay or prevention. Such a summary may then be used to inform an appropriate submitter’s request for FDA to review and consider an indication for metformin in high-risk patients with prediabetes. (Recommendation 5.4)
Fund additional type 2 diabetes prevention research. (Recommendation 5.12)
Fund the Special Diabetes Program for type 1 diabetes research in 5-year increments with annual increases addressing inflation costs. (Recommendation 5.13)
Fund research to identify and address factors that affect referrals to and patient uptake of diabetes self-management education and support. (Recommendation 6.11)
Increase funding for implementation research across multiple federal agencies (e.g., AHRQ, NIH,CMS, HRSA, IHS, CDC, VA, and DoD) to better translate team-based care into practice and test new team-based care models to improve diabetes care and outcomes. (Recommendation 6.12)
Investigate digital connectivity as a social determinant of health that impacts development and progression of diabetes. (Recommendation 6.13)

AHRQ = Agency for Healthcare Research and Quality; CDC = Centers for Disease Control and Prevention; CMS = Centers for Medicare & Medicaid Services; CMMI = Center for Medicare & Medicaid Innovation; DoD = Department of Defense; DPP = Diabetes Prevention Program; FDA = Food and Drug Administration; FTC = Federal Trade Commission; HRSA = Health Resources and Services Administration; HUD = Housing and Urban Development; IHS = Indian Health Service; NIH = National Institutes of Health; USDA = U.S. Department of Agriculture; VA = Department of Veterans Affairs.

^*Each recommendation is cross-referenced to the corresponding recommendation number in the report (1).

To develop and administer a national diabetes strategy and facilitate transagency collaboration, the NCCC recommends creating an Office of National Diabetes Policy. At the general population level, preventing type 2 diabetes and treating all types of diabetes require changes in social and environmental contexts. This necessitates coordinated engagement by health-related and non–health-related federal agencies whose policies and programs impact nutrition, food labeling and marketing, housing, transportation, and the ambient and built environments. All Americans at risk for and with diabetes must also have access to high-quality and affordable health care, and federal policies and programs must promote health equity. These recommendations are foundational to improve diabetes prevention and care.

Focusing diabetes prevention efforts among those at high risk has the potential to greatly reduce the incidence of type 2 diabetes and its complications. Safe and effective methods to delay or prevent type 2 diabetes include intensive lifestyle change programs, such as the National Diabetes Prevention Program, and use of metformin. However, uptake among the at-risk population is low and must be improved. This requires increased availability and awareness of such programs and reduced administrative and financial burdens to organizations and participants.

A significant gap in diabetes prevention and treatment is the mismatch between available resources and the ability of people with diabetes to access those resources. Insurers should cover key elements of type 2 diabetes prevention and diabetes treatment, and insulin must be affordable. Health care teams should be trained and designed to meet the care needs of people with diabetes. Use of virtual care modalities should be enhanced. Policies governing diabetes self-management training and diabetes devices must be updated to facilitate access.

Many areas require additional research and dissemination. These include intervention studies on social and environmental conditions associated with diabetes and its complications, type 2 diabetes prevention, barriers to uptake of diabetes self-management education and support, and implementation studies to better define models of team-based care. The National Institutes of Health is asked to summarize data from the Diabetes Prevention Program study (10) on the effectiveness of metformin to support a request to the U.S. Food and Drug Administration to approve an indication for metformin in type 2 diabetes prevention.

Summary

The NCCC strongly encourages Congress and the HHS Secretary to swiftly implement its recommendations. It is imperative that a national diabetes strategy be established to coordinate and monitor transagency collaboration and progress toward achieving these goals. Doing so will substantially benefit the health and quality of life of people at risk for or living with diabetes, promote health equity, and support clinicians as they assist patients with diabetes prevention and treatment efforts. Specialists in internal medicine have a singular and important role in facilitating these critical steps. These combined efforts will further leverage and maximize federal resources focused on diabetes prevention and treatment for the benefit of the U.S. population.